Management of PHT Avulsions with Dr Hardy & Dr Lefevre

: On today's episode, management of PHT evulsions. online physiotherapist, recreational athlete, creator of the Run Smarter series, and a chronic proximal hamstring tendinopathy battler. Whether you are an athlete or not, this podcast will educate and empower you in taking the right steps to overcome this horrible condition. So let's give you the right knowledge along with practical takeaways in today's lesson. bit of a different one today. I have two guests with me. I've got Dr. Alex Hardy and Dr. Nicholas Lefevre, and they are surgeons who specialize in PhD evulsions. So evulsion being like the detachment of the tendon from the sit bone. These two lovely guests dive into exactly what it is and how to best manage it. I first stumbled across Alex Hardy as he posted on the PHTE Facebook group and was posting his research that he's recently done, which I am thankful for. Thankful for that he's up to date and not only aware of the latest literature, but also being involved in it himself. And he was, after our recording, talking about some of the papers he's currently doing and that are about to be published, which are looking very good, very promising, and he'll be keen to share those and I'll share it on the podcast when it becomes available. And so I reached out to Alex about his recent publications and said, do you want to jump on the podcast and have a chat? He agreed and said, Oh, can I get my colleague Nicholas Lefebvre to come on as well? And we'll do like a Combined interview. He was my mentor and has taught me everything I know and all those sorts of things. And while I was a bit reluctant because having multiple guests is always a little bit awkward with steering the conversation and having something that's quite free flowing. He assured me that having Nicholas on would add to the value of the podcast itself. Present with some challenges. Not only was the language barrier a little bit iffy, but also taking your turns and answering questions and that sort of stuff was a little bit disorganized, but managed to do a fair bit with post interview editing to hopefully get it sounding a little bit smoother and without it sounding too jarring for you. So... Nonetheless, we got through a ton of really interesting content. I learnt a lot and I hope you do as well. I haven't done much around evulsions and about surgery and those sorts of things. And so what better to have the experts come on? And, um, I sort of got a good vibe from them, a good unbiased sort of, um, aspect, which I hope you get the same vibe as well. I hope you enjoy. Dr. Alex Hardy and Dr. Nicholas Lefevre. Thank you very much for joining me. Let's start off with some the talking about your, I guess, background, clinical qualifications and those sorts of things. Um, Nicholas, do you want to start off with a bit of a introduction? Yes. Hi everybody. I'm Dr. Nicolas Lefebvre, a senior sports surgeon with over 20 years experiences of in proximal and in surgery. Uh, I'm founder of the fast quartz, uh, sorry, with other than 1000 proximal hamstring groupers already done. And I work in a clinical Paris clinic, sport clinic. Yes, so I'm also a trained orthopedic surgeon. I did part of my training in New Zealand. That's not very far from you, Brody. Cool. Yeah, so I was trained by Nicholas for proximal hamstring tear and proximal hamstring abulsion. I think it's interesting because you don't get very often the chance to train with Nicholas and he said he's had tremendous experience with this specific pathology that I wasn't even aware of before joining the sports clinic. So yeah, it's really a chance to have him today. Very cool. Um, I think let's start off with, because most people that are listening to this podcast, they're not. doctors, they're not surgeons, they don't really have much of a medical background. So Nicholas, if you wouldn't mind, could you explain exactly what an avulsion fracture is or what the condition entails? So in fact, an avulsion refers to an injury where the tendon is forcibly detached from the bone insertion. You have acute evolutions, are sutured and often result from a traumatic event. And tight impact activity, whereas overload injury, uncorrected in a clinical picture of hamstring syndrome, occur gradually to repetitive stress and overuse. The mechanism of evolution often involves sudden hip flexion while the knee is hyperextendent. This can involve sudden acceleration of runners, football players, as well as forcible knee extension in especially in rugby, this injury can occur when a player is trying to stand up from the ground while being blocked or tackled by other players, causing forceful extension of the knee against resistance while the hip is flexed. Additionally, Klimberg can experience hamstring evolution during easy to understand is you've got to make a big difference between like tendinopathy, which is like a chronic disease that will grow during time, especially in runners. So you'll get discomfort at the insertion of the hamstring in the middle of the buttock. And the pain will basically increase with the workload that you will put on your thigh, whereas the avulsion is easy. honestly to diagnose clinically with really an extruded pain at the insertion of the thigh and a big hematoma that will appear after that. So even for a non-medical person, it's easy to understand that something's wrong. Cause like I've looked at the research a little bit and like the incidents of an evulsion and I know Nicholas, you talked about the sports scenarios when a sudden acceleration or those particularly highly traumatic kind of events can lead to that. Um, I've also seen a high incidence in people, the non-athletic population just slip, trip, like do the splits slip on ice and those sorts of things. Do you, I know you. you're a sporting background and you have a sports doctor, do you ever see that particular population? Yeah, it is very common to see those guys during our consultation and the splitting mechanism is very common. Also you can get people that you know, one of the other quite frequent incidents is water skiing. So people that would, you know, just do water skiing for leisure. They will get this specific, uh, hip hyper extension with the knee in full extension and, uh, those guys that may not be like professional athletes can really, um, have this type of, uh, ins this type of injury without being, you know, intense sports, Okay. And is it always present with bruising and that sort of traumatic thing? Because we did mention that there's Okay, there's the sudden incidence of like, you know, a very traumatic event, but then there can also be some sort of micro trauma from overuse, which, you know, typically is what a tendinopathy would develop into. But yeah, how can we separate the two for the from the micro trauma? So basically, there are, of course, a broad variation of presentation. So As I mentioned, the classical way of seeing people with an avulsion is really like excruciating pain. And it's really important to mention people can really feel that something is wrong. Sometimes people faint with this type of pain and the hematoma appears. But normally the hematoma will appear like in a few days after the injury. It also depends on the type of BMI, I would say. So if the guy is pretty big, maybe the hematoma wouldn't be that obvious clinically. But I feel that if, what we need to give as an easy message to understand is that if you feel a sudden, like really important pain, from the insertion of your hamstring, you need to see someone, you need to see a doctor, and you need to do an MRI. Because we will talk about this later, but the timing is really like a really important part of your care. Okay. And Nicolas, when you have people come to consult with you and they say, these are my MRI scans, I, it's... I've been told I have an avulsion. Do you recommend surgery for everyone? Is that like the approach that you suggest? The surgery is not systematically an aggregation, but in this pathology, you have to know that about all the people, even if they are not a sports level of practising, they need to be restored, they need to have a restored total re-incision. When you have a partial tear or a retraction, very minimal retraction, you can make medical treatment, but in overall all the indications for surgery, it's when you have a total tear and a massive retraction. Alex, you want to say something? Yes, so classically what appears in the literature and we actually have a research that has been submitted and accepted to the AGSM, but it's not out yet. But what we do see and what I think is easy to give as a guideline is if you have a free tendon avulsion, so an acute free tendon avulsion. Surgery is always an option, even if you are not a big sports enthusiast. And for partial abortion, so one tendon, if the retraction is lower than two centimeters, you can probably be fine without surgery. If the retraction is further than two centimeters, you need to see a surgeon. I'm not saying that you will be operated, but you need to see someone. And if it's less than two centimeters, a lot of people, like on Facebook groups are like, well, if I don't have surgery, well, how does it reattach itself? Like what's happening there? Can I go with it just reattached or can I, does it heal? Like what's happening with those? Um, I guess less severe retractions. In fact, for a patient not retrying surgery, conservationist treatment is possible. These include rest, ice application, physical therapy, focus on gradually restoring runoff motion, strange, and sometimes patch-like rich plasma, PRP injection. And you need a structured rehabilitation program. It's essential to ensure optimal recovery, typically lasts for about four to six months. and regular follow-up are necessary to monitoring progress and adjust the treatment plan as it did and sometimes we have to do surgery one, two or three months later because the restore is not good. Alex? So yeah, so I think that in an anatomic analysis, it's once again, it's not facts, it's what we feel. We feel that because the avulsion is partial, the other tendon will help to be like a guide for the healing for the other tendon to heal. Whereas if you have a free tendon avulsion, and we know that if you have free tendon avulsion, surgery is needed. And it is needed because obviously you don't have the same guide to help the tendon heal back to where they used to be. So I think that's the big difference between partial and complete. Is the presence or not of a guide for the, for the tendon to heal in a proper way? Gotcha. So we're looking at, okay, onset of symptoms, something that's quite severe, very high level of pain. We're looking at, uh, bruising some days after that really traumatic event. And obviously present with a traumatic event, because if we're trying to rule out, I guess if it's a very sudden. gradual onset, we're mainly suspecting a tendinopathy and not really something that's quite so drastic. But then looking after that event, looking at scans, if it is suspecting to be an evulsion, so getting an MRI, and then seeing what the severity is, what the retraction might be, is it a complete or partial, but then getting assessed to also look at strength and function. because if it's a partial tear, we want to see how much function there actually is and then use that data, I guess, alongside if it is a partial tear, what their ambitions might be athletically, what they want to return to, to then guide whether surgery or conservative management is the right option. Yeah, definitely. If you get a hamstring tennemopatin, it's a totally different approach because we have plenty of time. You see, it's the main difference between acute and chronic is in a chronic case, you've got plenty of time. So you want to have as many information as you can get to get the best decision for the patient. So we routinely use isokinetic testing to see what is the, what's called LSI, so leg symmetry index. So we compare. the strength between the hamstring on the injured side and on the healthy side. We look at what has been done already. So Nicholas mentioned the PRP injection. It could be a good option for insertional tendinopathy of the hamstring. We also see what has been done in the rehab and what are the level of impairment for those guys. But... For a chronic tendinopathy, we will never offer surgery as a first line of treatment. We will always be sure that rehab has been done properly, that PRP has been proposed to the patient, and if those two options has been, haven't been successful, then surgery can be an option. And you mentioned when it comes to surgery, that timing is pretty key. Um, what did you mean by that? So we did a study and we'll probably give you the link of the study that we did that was published in the AGSM, which is the journal of the American Orthopedic for Sports Medicine Society. And what we saw is that there is basically a big cutoff after 32 days or let's say one month. So if you get an operation after one month. you will have lower clinical results. And that's the big thing. You will have a much higher rate of reinjury. So that's what we want to avoid. And that is pretty easy to understand as basically you've got a tendon, and the tendon, when it's not attached, will tend to retract. So it will go further from the insertion. And so for us, surgically, it will be more difficult to reattach. And for you, the risk of re- rupture is much higher. And is that for partial evulsions and also for complete? Only for complete. OK, gotcha. And I guess that's when you would push surgery. Looking at that criteria we talked about before, complete ruptures would be, you know, push along for surgery a bit quicker than say partial because what I was thinking is if there was a partial evulsion and the medical team suggests try strengthening first, try conservative rehab and if that's unsuccessful then maybe surgery is down the track but you know rehab can take months and so you've probably passed that window for greater success post surgery. So yeah, it's good to know that there's a difference between the two. Nicholas, I want to go back to you. Like if someone has a complete evulsion and you do perform this surgery, like what's involved, like what's involved in terms of attaching the tendon and thereafter, like what happens day one, day two, those sorts of things. Ah, so you, after the surgery, you have to have a rest and you need six weeks. Six weeks is very important to have the healing of the tendon. After six weeks, you can start the rehabilitation. You can walk. You can do a lot of things. But between one week to six weeks, you have to have a rest, to have a brace, to protect the tendon healing. It's very important. Because most of the Ruruk tools occur between the first two first two months after the surgery. And we, like Alexan said, we recently identified the factor of risk of the rurutu in 140 patients. And we saw that it's the chronicity, the complete injury, and the activity, the big activity, too much activity after the surgery. So you need rest. breaks and rehabilitation after six weeks. Are you agree, Alexandre? Yes. Yes, so what we see regarding rehab in most sports injuries is we'll tend to do quicker and stronger rehab in basically all sports injuries, like ACL or whatever. In the hamstring evolution, It is really not the same discussion. You want the tendon to heal. So we're really moving to much more conservative treatments. Like after the surgery, we'll tend to delay the rehab because we've seen that it is not so much a problem. Like people will not get stiff. You will not get stiffer hip joint and you will regain your strength with time. So we tend to protect the tendon healing a bit more in the last years. I forgot to mention earlier, Alex, like when someone gets a scan and it shows like a tear, a hamstring tendon tear, would that be different from an evulsion or like, how could someone know the difference? Yeah, it is. It is like, there is this wonderful study that was done by another group that. describe what's called the ice cream sign. So basically on the MRI, you can see the two tendon, which is the congenital tendon and the semabemovirnosis tendon that insert on the ischium. And they basically appear like two scoops of ice cream. So you either have the two scoops or you've got a dropped ice cream sign when one scoop or two scoops are missing. And that's really the difference between the two presentation. But I must insist on the fact that if you get an MRI of your thigh, you can get a tear of the hamstring on people that are not symptomatic and, you know, discovering a tear of your proximal hamstring is not like a curse or whatever. It can get asymptomatic and the healing on the MRI. is not mandatory to get a proper hamstring that's not painful and working perfectly for your sports activity. I think that's really important because a lot of people I've had clients, uh, show hamstring tears and it turns out they've accidentally MRI the wrong side and it's been the healthy leg and they've never had any pain on that side. And so who knows what's lurking. before a hamstring tendinopathy, and then you develop pain and then it shows a tear, it could have been there prior. So it's very hard to determine and like, what's the actual cause of pain but confused me like you mentioned. A lot of people get scans and rescans. And I think you mentioned that, you know, healing these tears doesn't necessarily need to be the goal you could do some rehab. and work on strength and function and symptoms. But just if you have a hamstring scan down the track and it still shows tears, that's perfectly okay. Correct? Absolutely. And what's quite interesting is that we looked at the healing of the tendon after surgery. Uh, we did a mandatory MRI after a reattachment of the tendons and we saw. that some of the patients that had what we'll call a fibrous healing of the tendon, so a not perfect healing of the tendon that will look a bit like a tendinopathy, will have perfect results. And the main problem for patients and the main MRI criteria that will be associated with lower clinical results was what's called fatty infiltration, which is basically linked. to the chronicity of the injury, but MRI healing is, is not mandatory to, to do anything if you're asymptomatic, it's not a problem for me. Yeah. So we're mainly focusing on improvement in pain, improvement in function, um, returning to, you know, skill returning to sport and not necessarily saying you're better. You can return to sport once your MRI shows better images. It's more just focusing on the symptoms. Absolutely. I think that when you look at the incidence of proximal hamstring tendinopathy, that is not an uncommon pathology. And you look at the number that, uh, have to go through surgery that is like minor. It's really like, it's, it's just like Achilles tendinopathy for runner. There is like plenty of guys that will. go just fine. And if you do an MRI of their ankle, plenty of those guys have tendinopathy of their Achilles and there is nothing to worry about. Yep. Nicholas, I want to go back to you talking about after surgery. You mentioned ice, you mentioned rest, and then you mentioned going back to doing some rehab exercises, returning to rehab exercises. Do you have any guidance in terms of what exercises might be prescribed? What, what might be the best exercises after surgery? Yeah. Can you answer Alexander? Yes. So what we would recommend is at the beginning, we'll tend to do more isometric, uh, exercise, so no mobilization of the knee or the hip. And after that, we will move slowly to regaining the range of motion. And when the range of motion is. is good, which should appear around three months after surgery, you'll be able to move to more active exercise. When you look at tendinopathy, it's really not the same discussion because obviously there is no real risk of rupture. So what I would recommend for proximal tendinopathy is more eccentric exercise that will tend to be more efficient to treat tendinopathy. What are your thoughts on PRP for tendinopathy? I know you mentioned for an evulsion that maybe PRP can be recommended for someone before like, before recommending surgery. I know a lot of people with chronic PHT that are being recommended PRP injections. Based on what your understanding is of the research success rates and those sorts of things. Would, would that be good practice or when would someone consider getting a PRP for tendinopathy if, if at all? Well, I think there is two answers to that. So there is what we called EBP, E-E-B-P, so evidence-based practice. So if you look at evidence-based practice, there is honestly not the research to recommend PRP. The problem is that we don't have many options. So I know that in other countries, you can inject dextrose or you can inject all of the stuff. In France, you will get as an option steroids or PRP. And we know that steroids can increase the risk of tendon rupture, which we don't want. So PRP is, it's not that it's the best option. It's just that it's the only one. Gotcha. Yeah. Don't have much to work with. Okay, that's fair to say. We talked about delaying surgery if it is a full tear evulsion by one month can, you know, increase the risk of poorer outcomes, increase the risk of re-rupture. Are there any other risks of re-rupture or what might heighten someone's risk of re-rupture after surgery? It's a, we find a... We do a publication in AGSM and we find two risks of rupture. It's the chronicity, so the daily is 32 days, and complete rupture. That is the two major risks of rupture in the population. The age, the sex and the activities, it doesn't matter. surgical technique, inadequate rehabilitation, premature return to height and past impact activity, underlying health condition affect the tongue and heling. So yeah, it's really interesting to see that in this study, we found that, so Nicolas mentioned the chronicity, and what we found is that if you're treated after 32 days, basically the risk of rupture grows by two and a half. time what you have if you're treated before those 32 days. So it's really like, it's more than two times higher rate of re- rupture. So it's really like a big cutoff. And if, as we discussed, so complete avulsion compared to partial avulsion, complete avulsion is associated with a four times higher risk of re- rupture compared to partial avulsion. Because probably there is this guide helping you healing. in the case of a partial evolution. Okay. And I have a lot of clients with PHT, um, not an avulsion and they're having consults with surgeons. They're being recommended surgery in some cases. Um, I know this probably is in your field. It's more around the avulsion side of things, but do you have anything advice for people on that side of things like what guidance you have for them if they, um, I guess unique circumstances, obviously, uh, a key in this factor, but can we rely on any research or rely on any guidance in that sense? Alex? Regarding this, uh, this specific injury. So surgery is considered only in case of failed conservative treatment. So it's only in case of failed conservative treatment and, and you mentioned it earlier, it's only if there are impacting symptoms. So we will never operate on an MRI because as we mentioned, the rate of proximal hamstring tendinopathy on asymptomatic patients is pretty high. So the decision is made on a case by case basis. We will consider the factors as the severity of the symptoms, the impact on the patient's quality of life or on their sporting level. And we will be sure, we will make sure that the rehabilitation has been done properly. We will classically say six months. And we will offer, it's not mandatory, but we will offer a PRP injection just to avoid as much as possible surgery for those guys. Should people be worried about their, the severity of their scans when looking at, you know, the degree of tendinopathy, if it's showing that there is degeneration thickening, um, those sorts of things. So I think that on the MRI, which you need to look at is so in the acute phases, we will look at the retraction and the. degree of fatty degeneration. In the proximal hamstring tendinopathy, it's a complete different discussion. We will look, of course, at the degree of what's called, what we can call a version of the proximal tendon, which is a partial version due to a pathologic healing of the tendon after overuse trauma. And what's... quite funny is that surgically, it is easier when there is a big tendinopathy than when there is a small tendinopathy because surgically what will happen is we will go to the insertion of the tendon and when there is a big tendinopathy, it will be quite easy because you will only do a small incision and basically the tendon will just move away from the ischium because it's some kind of almost rupture. Does that make sense? And so it's easier for us, whereas when there is small tendinopathy, surgically it's more difficult. But regarding the degree of tendon degeneration as a prognosis, we're currently doing a research, especially on those guys, to see first of all how they do surgically because it is a It's not reported in the literature. And we have to say that we feel that they might, they might do worse than acute cases because of the chronicity of the problem. Uh, but we, we still do not know if the degree of tendon, uh, degeneration is a prognosis for the result for those patients. Okay. Um, Nicholas, I want to come back to you and. I've always wanted to ask surgeons about scar tissue because there's a, I don't know, there's been this, some people are being told that they have a lot of scar tissue around a tendon and that's impacting the sciatic nerve. I speak to some people who are like, you know, scar tissue doesn't really work that way. Can you? highlight or maybe help decipher does this phenomenon actually exist? What's the role, if any, does scar tissue exist? Um, can you share your thoughts on that? Uh, regarding scar tissue. Uh, so you've got, you've got, I think two discussion. We've got the scar tissue that will, you know, form between the tendon and the ischium, which is one thing and the, the only consideration about this one is Is it strong enough to hold the tendon when you're going to put some tension on it? And there is the scar tissue. That is the big problem. The scar tissue around the tendon and when the tendon is retracted. And this is where the sciatic nerve is a problem because if the tendon heal, like towards what's around him, it can heal on the sciatic nerve and it can cause, you know, sciatic discomfort with the healing. Regarding how it happens, what we see surgically, and Nicolas does much more than me chronic cases, what we see is basically there is an unanatomic healing with like some kind of fibrosis which is like scar tissue, but it's like, I don't know how to describe it for people. who have never been to an operating room, but it's basically a mess because you're not able to see properly anatomic landmarks. And this is like the nightmare of surgeon. I've seen surgery regarding those chronic cases. I've seen them in New Zealand. I've seen them in England. I've seen them in France. And this is the nightmare for a surgeon because when you have discomfort on the sciatic nerve, after a chronic avulsion, you want to help the patient, you want to help them get better and to do that, you need to mobilize the tendon and if you can, bring him to the ischium. If you can't, maybe do an allograft between the tendon and the ischium, but you need to detach the tendon from the sciatic nerve. And it is one thing to have a sciatic discomfort. It is another thing to not be able to move your feet. If you try to release the tendon from the sciatic nerve and you cut the sciatic nerve or you damage the sciatic nerve and after that you've got a mobility impairment, that is definitely not what you want to offer to your patient. And it is really a very, very difficult surgery. I would say it is probably the most difficult surgery I've seen because of the risk that you put your patient to. And personally, I tend to give those surgeries to Nicholas because I know that he's much more skilled than me and much more experienced than me in this type of surgery. And this is really another thing that I want to give as a good message for the guys listening to the podcast. And if you have a chronic injury with esoteric involvement. You want to go to a surgeon that have big, big experience on those type of injury. And I'm talking like guys with who has done like maybe more than two or 300 of those cases, because you're really putting your leg at risk when you go through surgery for this. Would they be able to identify that on MRI scans to see that the scar tissue? is impacting the sciatic nerve. You don't know until you've actually start the operation. Well, what we will be able to assess on the MRI is the position of the tendon, which is always very close to the sciatic nerve. And what we'll be able to discuss on the MRI is if we are going to be able or not to put the tendon back to the ischium. So if we need an allograft or not to do that. And that's probably the only thing. the involvement of the sciatic nerve in the chronic injury is mainly clinic. So you will get, you know, those neuropathic pain that will go all the way to the leg. And that is for me how to discuss the involvement of the sciatic nerve in some kind of, you know, scar tissue. And just want to say when it's a very severe clinical... rupture with sciatic pain. Sometime in the MRI, you can saw massive fibrosis just above the nerves and you can saw a hypertrophy, hypertrophy of the nerves. And you can see when you compare the nerves left and right and the pathologic and the normal nerves, you can see a difference between the nerves. So you can know, you can... You know that the surgery will be very difficult and I recommend for the surgeon do an Electromyogram before the surgery to make sure the nerve is correct and to have a reference after the surgery to look after the nerve after the surgery do an Electromyogram of the nerves. So in New Zealand when they did those cases they used a device that's called checkpoint which is like basically a small electric device that will stimulate what's around it. And they will use it to locate the nerve because finding a nerve in an acute cases is very, very easy. Because you've got the huge hematoma that will basically dissect all the area, and you will find the nerve very easily. But when the hematoma is gone, and that is another thing that we look on the MRI. For us, the hematoma is a very good, very good news because as big the hematoma is, as big the location is open and everything is separated and it's very easy for us. When the hematoma is gone, it's much more difficult. So checkpoints helps you to find where the nerve is and that's a good help in kind of chronic care cases. The scar tissue that potentially could impact the sciatic nerve is just for ruptures. It's not for a tendinopathy. Oh yeah. I have seen people suspect that they've got this chronic pain. They've had this chronic tendinopathy. Then they're just starting to develop like sciatic nerve symptoms. And they think that it's scar tissue that's impacting. Doesn't that's not the case. No, that's two different problems. The sciatic nerve can get involved. Uh, mainly in case of chronic complete evolution and more often in retracted tendon and big emetoma. Yes. Okay. Um, thanks for clearing that up. Um, if people are interested in consulting with you, if they've had MRIs or they suspect evulsions and those sorts of things, um, Do you offer in-person consults? Do you offer online consults, international clients? Like, what do you recommend if people are listening to this and they want to know more? Yeah. So it's pretty easy. We've got four orthopedic surgeons that basically operate every day. And it's really important to understand that when we say that timing is important, We treat those guys just as if they had a fracture. So when they come to our consultation, they will get the MRI the same day and they will get the surgery the same week. So we, and that's what I learned from Nicolas Lefer. And Nicolas would say, okay, it's a hamstring evulsion. You need to get the MRI today. Okay, it's a hamstring evulsion. When is your next operating room? You need to operate on the guy. And timing is really important. So we do have an email address that's called hams And with the email address, we've got an English-speaking secretary that can refer to us, MRI scans, and also we do a inpatient consultation and we do also teleconsultation. So how do you say that? Telehealth, yes. Telehealth consultations, yes. Yeah, telehealth. And that's one of the things that I learned from Nicolas is we have people coming from all Europe to get surgery for hamstring abortion to the clinic. So we do have an easy pathway for those guys to be treated as quick as possible. Great. Nicolas, anything to add there? No, I think everything I said. The thing, the take-home message, it's the injury. It's acute injury. It's a big hematoma. It's a total root two. You need to have MRI in emergency. You have to see a surgeon quickly. on the week and you need to have surgery before one month but in fact before two weeks. If you have the surgery before two weeks you will have a very good healing. After that, after one month, you have good results but the results are less better. So the thing is you have to go quickly with your medical practitioner, surgeon, radiologic you have to be quick. Just I have to say that. Alex? Yes, and one other thing we didn't discuss, but I think one of the important findings that we found in another study is that sonography is not an option. It is like a very important message. Sonography is a terrible exam for proximal hamstring avulsion. It has a sensibility around 50%. So basically it's flipping a coin. And what we found, what is interesting is that when you get a sonography, uh, you will tend to be operated, uh, later and you will have lower clinical results. So sonography should not be an option for those guys. You should go straight to MRI. MRI will tell you what's happening. So a sonography is a type of scan that someone might get. Uh, Uh, sonography is like a eco-graphy like, uh, for pregnant ladies. Yeah. And like an ultrasound, ultrasound. It's ultrasound. We say sonography, but it's ultrasound. Yep. Ultrasound is not an option for those guys. Yeah. Because it's too hard to visualize and diagnose and work out the severity and determine whether it's a good candidate for surgery. Exactly. Okay. Very good to know. So MRI, um, is a must. Yes. Very good. Is there any other, uh, like I'll be sure to, um, provide that email that you recommended I'll provide that in the show notes, but while I'm putting everything together, is there any other resources or website or something for people to go to, to learn more about what your team is doing? So, yes, there is the, uh, show. That come, which is the website and also. What we'll do, if that's okay with you, Bordy, we'll give you all the later papers that we've published on the subject, because what happened is when I joined the Chirurgie du Sport with Nicolas Lefebvre, he has been working on the cohort for years, which is called the FAST cohort, and since I entered the group, I've been working on analyzing all the results, and that's really important to know. how to improve and what are the results and what are what we can offer to patients reasonably. And so we've got like maybe five recent studies and we've got many more on the way, but I'll be able to provide because they're open access so you can get access to them pretty easily. Great and any other papers that you work on in the future, let me know because I'll be more than happy to. not only share it out, but maybe do future podcast episodes on just talking about that paper and give people more answers. Because as you probably know, there's not a lot of research on PhD. There's not a lot of research on evulsion. So thank you for not only offering great standards, like you say, MRI and surgeries, quick follow ups and those sorts of things, but also doing the research yourselves to find better ways to... get better outcomes. So I want to thank you, Nicolas. I want to thank you, Alex, for both coming onto the podcast and sharing your insight and your expertise. It's been very good to have you both on. So thank you. Thank you. Thank you very much for having us. It was a real pleasure to discuss this, as you said, unpublished and not so well-known pathology. So discussing and making it easy for the public to understand is definitely a good way to... help the treatment for those guys. Knowledge is power.